Thursday 27 February 2020 ★ FINANCIAL TIMES 11

Opinion

A

merican democracy plays

out in the classical splen-

dour of Washington and in

domed statehouses from

sea to rising sea. It also

plays out in Las Vegas’s Bellagio Ball-

room number six, between Frank

Sinatra Drive and a chain diner with the

unpromising name of Eggslut. There is

no doubt as to the more impressive

spectacle.

Hotel housekeepers, still uniformed

and name-tagged, are among the

low-paid Nevadans who caucus for

Bernie Sanders as the Democratic

presidential nominee. In going to his

side of the chandeliered room, they

have somewhat bucked their formid-

able union. The invisibility of cleaners

has become a cinematic trope (Roma,

The Chambermaid) but these ones are

momentarilyofworldimport.

That Mr Sanders wants to improve

their lot is not in question. Some leftists

choose purism over half a loaf, but he

tends to vote for what redistributive

measures come before him in Congress.

He would give Americans universal

healthcare, statutory paid leave and

other staples of the developed world.

This has encouraged the notion that

he — and his rival Elizabeth Warren —

would Europeanise the US. The likeliest

heirtotheseseptuagenarians,Congress-

woman Alexandria Ocasio-Cortez, is

another who looks admiringly across

theocean.

So widespread is the idea of conver-

gence with Europe, and so true in parts,

it is also incumbent to state where it

breaksdown.

What the US left appears to want is

social democracy as understood by

Robin Hood. It would tax astronomical

wealth to fund popular programmes.

It would not ask much more of the mid-

dle or even the upper middle classes. Ms

Warren’s signature tax spares all house-

holds with a net worth below $50m. Mr

Sanders has more people in his cross-

hairs but still zeroes in on the very rich.

With an election in the offing, this selec-

tiveapproachtorevenueishardtofault.

There are lots of votes in a raid on Wall

Street. There are fewer in a raid on the

handsomesuburbsaroundTampa.Poli-

ticianshavetobeartistsofthepossible.

This does, however, put them at some

odds with the social democrats of

Europe, who tax more citizens more

heavily. Denmark does not achieve

fiscal receipts of 45 per cent of national

output by going after a gilded sect of its

population, languidly rolling Fabergé

eggs to each other across marble floors.

Nor does France (46 per cent) or Ger-

many(38percent).

The US tax take is just 24 per cent.

The purring Train à Grand Vitesse, the

social mobility that is more than theo-

retical — Democrats are right to want

these things for their country. They just

misunderstand the implications for tax

policy. Or rather, they understand them

all too well and choose to duck the

resultant politics. Even the party’s most

progressive field for a generation or two

does not contemplate taxes that are

Europeaninbreadthanddepth.

Pressed on this point, Democrats

invoke the sage that was Willie Sutton.

The criminal of yore targeted banks

because, he said, with unanswerable

logic, “That’s where the money is.” In a

country with America’s titanic inequali-

ties, the top 1 per cent is where the

money is. It is the obvious percentile to

pressforrevenue.

Not all economists are certain these

numbers work out. Doubts over costing

have helped to all but kill Ms Warren’s

campaign. But even if the arithmetic is

sound, there is the larger issue of princi-

ple. In targeting just the richest, Demo-

crats rather imply that a welfare state is

onlyworthwhileinsofarassomeoneelse

paysforit.Itisnotaninherentgood.Itis

not a nation’s binding agent. In this

sense, the Sanders and especially the

Warren platform is a tacit concession to

the Republican view of the world, with

tax as a burden, not what the jurist

Oliver Wendell Holmes defined as

“what we pay for civilised society”. The

Democratic appeal is less to Nordic uni-

versalism and solidarity than to the

noblesse oblige of a remote overclass

whowillnotmissthemoney.

You can sense that Mr Sanders burns

to make the higher case: that patriotism

entails a material commitment to one’s

fellow citizens, not just flag-waving and

anthem-warbling, those tellingly inex-

pensive pursuits. But then President

Donald Trump wants him to make it

too. The implied taxes would have mid-

dle-class voters, including those who

abhor him, wondering at the cost of a

presidential change in November. The

Democrats understand this no less well.

And so even the most leftwing bunch in

decades proposes a social democracy

thatisnotverysocial,norallthatdemo-

cratic, and as European as the Eiffel

TowerthatdisfigurestheVegasStrip.

[email protected]

This selective approach

to revenue is hard to fault.

There are lots of votes in

a raid onWall Street

Democrats are targeting the riches of the 1 per cent

identify the most complicated situa-

tions and pass them on to doctors and

nurseswhoarereadytohandlethem.

“Our strategy is to enable the frontal

cortexofdoctorsratherthanlobotomis-

ing them,” says Bill Evans, managing

directorofRockHealthventurefund.

The fund was a seed investor in Virta

Health, which uses constant monitoring

and AI to track and treat patients with

type 2 diabetes. The computer alerts

(human) health coaches and doctors

when the data suggest patients need a

nudge or a dosage change. An early clin-

ical study found that more than 60 per

cent of patients reversed their symp-

toms. The company is so confident

that customers, including Blue Shield of

California and US Foods, only pay if the

aggregate patient results hit perform-

ancetargets.

Ifpayforresultsspreads,theoutcome

could be even more revolutionary —

and possibly frightening — than a robot

surgeon.

[email protected]

when the Dow Jones Industrial Average

dropped 9 per cent in minutes and

bounced back up again. Wrong calls on

healthcare are a very different matter,

and many medical decisions involve

choosingbetweenimperfectoptions.

In some ways, the challenges ahead

for AI in medicine are more like those

faced by Uber, Waymo and the other

designers of driverless cars. Machines

are great at monitoring and handling

straightforward situations — like driv-

ing down an uncrowded highway. But

city streets and traffic jams are com-

pletely different. And designing the

algorithms is only the first step. Win-

ningpublictrustwillbefarharder,espe-

cially after the 2018 crash in which an

Uber vehicle killed a pedestrian while

its back-up safety driver was streaming

atelevisionshowonherphone.

When it comes to medicine, most AI

experts say that we are decades away

from eliminating the need for doctors

and nurses entirely. Success will come

more quickly for applications that build

in the human touch. These use AI to

$270bn,accordingtoHFRdata.Traders

lost their jobs all over Wall Street and

the City of London as strategies that

relied on computers to spot opportuni-

tiesandplacerapid-firetrades—includ-

ing high-frequency trading — exploded.

By 2009, HFT accounted for 60 per cent

of daily US equity trading, and it

remainsabovehalf.

Experts in healthcare technology

argue that the use of AI and machine

learning will move much more slowly

because of the need to secure regulatory

approval and the dire consequences of

gettingdecisionswrong.

When trading computers make mis-

takes — or contribute to panic — the

trades can be reversed. Indeed, that’s

what happened in the 2010 flash crash,

UCHealth’s chief innovation officer.

“Now, instead of one nurse monitoring

eight people on a ward, she can monitor

8,000peopleathome.”

At a time when insurers and public

andprivatehealthcaresystemsalikeare

struggling to contain costs, the attrac-

tion of artificial intelligence is strong.

Some 367 healthcare AI start-ups

received $4bn in funding last year,

according to CB Insights. Investors are

plunging into everything from sophisti-

cated scheduling programmes that

maximise the use of operating rooms to

prediction systems that read mammo-

grams or help gastroenterologists

decide in real time whether to remove a

polypduringacolonoscopy.Theconsul-

tancy Accenture predicts that machine

learning will create $150bn in annual

healthcare savings in the US alone by

2 026.

Many individual physicians have long

been sceptical that machines can

replace the personal touch. But atti-

tudesareshifting.AnAmericanMedical

Association survey last year found that

36 per cent of doctors believe digital

health tools — particularly telemedicine

and remote monitoring — definitely

boost their ability to care for patients,

upfrom31percentin2016.

Insomeways,healthcareisnowatthe

point where computer-driven financial

trading was in the early 2000s. Back in

2005, computer-driven hedge funds,

which use algorithms to follow market

trends, managed less than $50bn in

assets. By 2014, that had ballooned to

I

fartificialintelligenceinhealthcare

brings to mind visions of robot sur-

geons, BioIntellisense’s stick-on

sensor is bound to be a disappoint-

ment. Just 3 inches wide by 1 inch

tall, this plastic and metal double hexa-

gon was cleared last month by the US

Food and Drug Administration for

remote monitoring of vital signs with

medical-gradeaccuracy.

Doctors at UCHealth, which runs 12

Colorado hospitals, say the device will

let them send patients home earlier

while still monitoring their respiratory

rate, resting heart rate, skin tempera-

ture and even body position. The data

can then be fed into computers that use

machine learning to spot people who

might need more attention, allowing

early intervention and avoiding emer-

gencyhospitalvisits.

UCHealth has already used computer

surveillance to fight sepsis, a potentially

fatal complication from infection, on its

wards. In its first six months, that track-

ingsystemreducedthetimefromrecog-

nition of sepsis to treatment by two

hoursandcutmortalityby30percent.

Such uses will also save money

and staff time, says Richard Zane,

The AI

doctor will

see you now

In some ways, medicine is

where computer-driven

financial trading

was in the early 2000s

T

he coronavirus outbreak is

onthevergeofbecomingan

official pandemic. Since

December, the disease

known as Covid-19 has

spread from China to infect more than

81,000 people in more than 40 coun-

tries,killingmorethan2,700people.

No country alone can cope with rap-

idly spreading pandemics; we need to

develop a global response. Timely

access to data is vital. The local govern-

ment in Wuhan probably missed a win-

dow to shut down this outbreak by fail-

ing to act in early December, after

detecting a cluster of lung infections

amongworkersfromonemarket.

Singapore provides exemplary

reporting on the transmission details of

each case. However, similar data from

China are not yet available. Canada fell

short in initial reporting during the

2003 Sars epidemic but has substan-

tiallyrevampeditsdatasystems.

To address this issue, the world

should consider establishing a global

surveillance facility, modelled after the

hugely successful Gavi, the vaccine alli-

ance. Such a facility, based in the World

HealthOrganizationbutwithindepend-

ent accountability, would provide coun-

tries with funding and technical assist-

ance during outbreaks. It would help to

buildresilientsystemsbeforeepidemics

strike. If the world’s largest economies

collectively contributed $2bn a year,

that would allow us not just to build the

fire station and pay firefighters but also

topreventfires.

Countries are, in theory, supposed to

report outbreaks to WHO through the

International Health Regulations.

WhiletheIHRisalegalobligation,polit-

ical incentives or fear of economic dis-

ruption means timely reporting doesn’t

alwaysoccur.

Public health systems can learn les-

sons from the global financial sector,

which has appropriated epidemiologi-

cal terms such as contagion or surveil-

lance. In the 1960s, the IMF made its

lending contingent on national income

accounts. It invested heavily in helping

countries improve their data allowing it

to track financial flows. Bank regulators

now stress test banks, and a new epi-

demics body could use the IHR to test

whether countries can provide com-

plete,quickandtransparentreporting.

The World Bank has a specialised

agency to sell political risk insurance to

companies. A similar system could pro-

vide no-fault epidemic insurance to

responsible countries with strong and

open health data systems. That would

provide incentives to report data,

insteadofhidingit.Increasingthesizeof

the World Bank’s pandemic bonds and

linking them to improved data gather-

ingcouldplayarole.

Tackling the dramatic means fixing

the routine. Only 3 per cent of the

world’s children who died in 2010 had

a proper medical certificate of death.

The new global surveillance facility

could strengthen routine reporting, by

replicating innovations such as India’s

MillionDeathStudy,whichtracksaran-

domsampleofallhomestoreliablydoc-

ument the causes of death. The facility

could also help countries apply modern

genomics to test samples and monitor

antimicrobialresistance.

Flu shots are updated annually

because more than 80 labs around the

world share information on the preced-

ingyears’strains.Asystemtostudynew

infections in hunters or others exposed

to animal viruses could provide early

warningofemergingthreats.

Investing in tracking and controlling

diseases saves money. Smallpox eradi-

cation cost $300m, but generated more

than $27bn in savings. An outbreak of

the plague in India in 1994 cost up to

$2bn. Quick action in 2001 averted a

smaller plague outbreak in northern

India by applying cheap, basic 19th-

century public health practices to trace

contactsandenforcequarantine.

Viruses do not respect borders.

Science also needs to think beyond

themtoimplementglobalsolutionsthat

willkeepussafer,healthierandricher.

The writer is a professor of global health at

the University of Toronto

WHO must

learn from the

IMF to stop

pandemics

A global group is needed

to gather data on

outbreaks and stress test

public health authorities

A

biy Ahmed has won two

important votes. In March

2018, Ethiopia’s now

defunct ruling coalition

made him prime minister.

Last October, Norway’s Nobel commit-

tee, impressed by his subsequent

actions on human rights and conclusion

of a peace deal with Eritrea, picked him

aswinnerofthe2019NobelPeacePrize.

Now Mr Abiy must win the election

that really counts — in August, when he

and his newly formed Prosperity party

face the Ethiopian people in a general

election.Iftheexerciseisfreeandfair,as

Mr Abiy has promised, there is no guar-

anteeheorhispartywillwinit.

What happens in Ethiopia matters.

After 15 years of near double-digit

growth, Africa’s second-most populous

country, with nearly 114m people,

has left behind its famine-stricken

image and become a talisman for

development.

Though still very poor, the country

has made huge strides in health, educa-

tion and poverty reduction. Life expect-

ancy has gone from 52 at the turn of the

century to 67. The economy has grown

more than 10-fold in the same period.

Despite complaints that the elite has

enriched itself, Ethiopia has one of the

most even distributions of income on

thecontinent.

This happy narrative is undermined

by one thing: the political reality. While

MrAbiyisstillfetedabroad,hisimageat

home has taken a battering. The peace

process with Eritrea has stalled. Oppo-

nents say Mr Abiy is egotistical, even

power-hungry. “We fought against a

one-party dominated system,” says

Jawar Mohamed, a former ally turned

political rival. “Now he’s trying to create

aoneman-dominatedsystem.”

TheAddisStandard,amonthlymaga-

zine, accuses Mr Abiy of filling up the

jails again with political prisoners and

carrying out military bombardment of

armed opposition forces in Oromia, the

mostpopulousregion.Thegovernment,

reeling from ethnic vitriol on the

airwaves, has passed a controversial law

curbinghatespeech.

Muchofthebacklashrelatestoacom-

plex tussle between Mr Abiy, an “Ethio-

pianist” who stresses the unity of the

state, and those who see the nation

through an ethnic lens. Visitors refer-

ring to Ethiopia as a “nation” are often

told that, under the constitution, it is a

“nationofnations”.

The 1995 constitution, enacted after

the 1991 overthrow of a ruinous Marxist

regime, emphasised ethnicity by divid-

ing the country into nine supposedly

ethnically integral regions. This was

partly designed to camouflage the fact

that, in reality, the country was being

run by Tigrayans, who make up only 6

per cent of the population, but who led

the revolution and implemented the

reforms that brought spectacular

growth.

Mr Abiy, in a policy that looks lauda-

ble from afar, has sought to de-empha-

sise the importance of ethnicity. He has

advanced a concept ofmedemer, an

Amharic word meaning “synergy”, vari-

ouslymockedasvacuousorcriticisedas

a dangerous grab for power in the name

ofnationalunity.

MrAbiyhasalsodisbandedtheEthio-

pianPeople’sRevolutionaryDemocratic

Front, the former ruling coalition made

up of ethnic parties from Oromia,

Amhara, Tigray and the Southern

Nations. He has replaced it with an

economically centrist, non-ethnic

Prosperityparty.

His advisers insist this was the right

thing to do, bringing previously

excluded minorities into the political

process. But the Tigrayan political

establishment, largely purged by Mr

Abiy, has refused to join. Tigray now

operatesinopenhostilitytothecentre.

In other regions too, Mr Abiy’s

message of unity has backfired.

Ironically, opposition is among the most

severe in Oromia, his own region,

which in 2018 wildly celebrated Mr

Abiy’s ascent as a victory for a long

marginalisedpeople.

Now he stands accused of betraying

those aspirations by stressing an Ethio-

pianist agenda. Lemma Megersa,

former president of the Oromo region,

has fallen out with him as a result. Now

defence minister, Mr Lemma opposes

MrAbiy’shurriedformationofthePros-

perity party. If Mr Lemma were to quit

thegovernment,itcouldseriouslyerode

Mr Abiy’s electoral chances in Oromia,

andnationally.

Tensions are inevitable. Mr Abiy has

taken the lid off decades of repression.

Heinvitedbackgroupsthatoncesought

to overthrow the state by force. Still,

critics may be right that the transition

hasbeenbotched.

MrAbiydoeshaveincumbencyonhis

side. His party controls the state

machinery and finances. Assuming

elections go ahead in August — and they

could yet be derailed — his party might

well scrape a victory. That would give

Mr Abiy five more years. At the end of

that period, it will be interesting to see if

theNobelcommitteehasanyregrets.

[email protected]

He has taken the lid off

decades of repression, but

the transition of power has

arguably been mishandled

Abiy’s message of unity in Ethiopia has backfired

Prabhat

Jha

AFRICA

David

Pilling

AMERICA

Janan

Ganesh

COMPANIES

Brooke

Masters

FEBRUARY 27 2020 Section:Features Time: 26/2/2020 - 18: 33 User: alistair.hayes Page Name: COMMENT USA, Part,Page,Edition: USA, 11, 1